Bill Text: MI HB4884 | 2023-2024 | 102nd Legislature | Introduced
Bill Title: Insurance: no-fault; treatment and service for injuries; revise standards and procedures for utilization reviews. Amends sec. 3157a of 1956 PA 218 (MCL 500.3157a).
Spectrum: Moderate Partisan Bill (Democrat 48-9)
Status: (Introduced) 2023-06-29 - Bill Electronically Reproduced 06/28/2023 [HB4884 Detail]
Download: Michigan-2023-HB4884-Introduced.html
HOUSE BILL NO. 4884
A bill to amend 1956 PA 218, entitled
"The insurance code of 1956,"
by amending section 3157a (MCL 500.3157a), as added by 2019 PA 21.
the people of the state of michigan enact:
Sec. 3157a. (1) By rendering any treatment, products, services, or accommodations to 1 or more injured persons for an accidental bodily injury covered by personal protection insurance under this chapter after July 1, 2020, a physician, hospital, clinic, or other person is considered to have agreed to do both of the following:
(a) Submit necessary records and other information concerning treatment, products, services, or accommodations provided for utilization review under this section.
(b) Comply with any decision of the department if a provider elects to pursue an appeal under this section.
(2) A physician, hospital, clinic, or other person or institution that knowingly submits under this section false or misleading records or other information to an insurer, the association created under section 3104, or the department commits a fraudulent insurance act under section 4503.
(3) The department shall promulgate rules under the administrative procedures act of 1969, 1969 PA 306, MCL 24.201 to 24.328, to do both of the following:
(a) Establish criteria or standards for utilization review that identify utilization of treatment, products, services, or accommodations under this chapter above the usual range of utilization for the treatment, products, services, or accommodations based on medically generally accepted standards.
(b) Provide procedures related to utilization review, including procedures for all of the following:
(i) Acquiring necessary records, medical bills, and other information concerning the treatment, products, services, or accommodations provided.
(ii) Allowing an insurer to request an explanation for and requiring a physician, hospital, clinic, or other person to explain the necessity or indication for treatment, products, services, or accommodations provided.
(iii) Appealing determinations.
(4) If a physician, hospital, clinic, or other person provides treatment, products, services, or accommodations under this chapter that are not usually associated with, are longer in duration than, are more frequent than, or extend over a greater number of days than the treatment, products, services, or accommodations usually require for the diagnosis or condition for which the patient is being treated based on generally accepted standards, the insurer or the association created under section 3104 may require the physician, hospital, clinic, or other person to explain the necessity or indication for the treatment, products, services, or accommodations in writing under the procedures provided under subsection (3).
(5) If an insurer or the association created under section 3104 determines that a physician, hospital, clinic, or other person overutilized or otherwise rendered or ordered inappropriate treatment, products, services, or accommodations that were not reasonably necessary under section 3107, or that the cost of the treatment, products, services, or accommodations was inappropriate not reasonable under section 3107 or otherwise in accordance with this chapter, the physician, hospital, clinic, or other person may appeal the determination to the department under the procedures provided under subsection (3) not later than 1 year after the physician, hospital, clinic, or other person received payment from the insurer or the association created under section 3104. If a physician, hospital, clinic, or other person appeals the determination under this subsection, the insurer or the association created under section 3104 must provide the department and the physician, hospital, clinic, or other person the methodology used to determine the payment or reimbursement made by the insurer or association created under section 3104. The methodology provided under this subsection must provide any adjustment made to the amount payable to the provider under Medicare on a form approved by the director.
(6) As used in this section: , "utilization
(a) "Generally accepted standards" means standards or guidelines that are generally relied on by medical professionals or others rendering treatment to an injured person, including generally accepted practice guidelines, evidence-based practice guidelines, or any other guidelines developed by the federal government or national or professional medical academics, associations, boards, or societies. Generally accepted standards do not include any set of standards or guidelines developed by private, for-profit corporations for commercial gain.
(b) "Utilization review" means the initial evaluation by an insurer or the association created under section 3104 of the appropriateness in terms of both the level and the quality of treatment, products, services, or accommodations provided under this chapter based on medically generally accepted standards.
